Basic Information
| Provider Information | |||||||||
| NPI: | 1558314922 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INDIANA HEART ASSOCIATES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 920 N SHADELAND AVE | ||||||||
| Address2: | SUITE G1 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462194898 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173559783 | ||||||||
| FaxNumber: | 3173559760 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 W JEFFERSON ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | FRANKLIN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461312147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177367651 | ||||||||
| FaxNumber: | 3177367337 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 06/23/2008 | ||||||||
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| AuthorizedOfficialLastName: | YELETI | ||||||||
| AuthorizedOfficialFirstName: | RAMARAO | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3176218666 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 50003647A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 2000201000E | 05 | IN | MEDICAID |